LYMPHOSTASIS, 
A Rehabilitation of Chronic Rheumatism. 
BY 
Dr. HANS FROELICH, 
ST. LOUIS, MO. 
REPRINTED FROM MEDICAL MIRROR, JANUARY, 1894. 
ST. TOUTS : 
CONTINENTAL PRINTING CO. 
1894. The editor of the Medical Mirror desires to draw the atten- 
tion of readers to the leading article of this issue, with the title, 
“ Lymphostasis, or Chronic Rheumatism.” This is a very import- 
ant and valuable addition to the fund of medical knowledge. Dr. 
Hans Froelich, after years of study and observation, unquestion- 
ably is the first one to show the mutual pathological and anatom- 
ical basis and etiology of hysteria, traumatic neurosis, neuritis, 
neuralgia, and neurasthenia, with the chronic rheumatic conditions. 
The name given to this pathological state is surely well selected; 
lymphostasis means obstruction in the lymph channels, and surely 
with the evidence before us, in the article referred to, the point is 
well taken. The communication is not only of great value from a 
scientific stand-point, but it is presented in a terse, original and most 
thoroughly interesting way, and we are confident that it will make 
a profound impression in the field of pathology, and result in the 
prominent association of the name of Dr. Hans Froelich with that 
name that is expressive of those diseased conditions, namely, Lym- 
phostasis. 
[Leading editorial in tlie Medical Mirror for January, 1894.] LYMPHOSTASIS, 
A Rehabilitation of Chronic Rheumatism. 
BY 
Dr. HANS FROELICH, 
ST. LOUIS, MO. 
REPRINTED FROM MEDICAL MIRROR, JANUARY. 1894. 
ST. LOUIS : 
CONTINENTAL PRINTING CO. 
1894. LYMPHOSTASIS, 
A Rehabilitation of Chronic Rheumatism. 
BY 
Dr. Hans Froelich, St. Louis, Mo. 
It may be a difficult undertaking 
to revive an old fellow, who has more 
or less officially fallen into disgrace, 
just as it would really be one of the 
greatest achievements of modern 
times, if one by ignoring a disease could 
cause it to cease to exist. I could 
hardly believe my eyes, when I found 
that chronic rheumatism was not even 
mentioned in modern text-books on 
pathology. Does it perhaps pain less 
when treated with disdain by the 
priests of science? It is interesting to 
note that that old common-place creat- 
ure of medical ignorance, hysteria, 
is being considered scientifically, just 
as if those gentlemen knew something 
about it. The neurologico-scientific 
jargon so frequently used in connec- 
tion with hysteria reminds me of an 
experience I had in my first semester. 
It occurred during my first and last 
attendance at the psychical college. 
The professor while teaching Hegel’s 
Philosophy made use of the expres- 
sion £ £ Das Erkennen ist das in sich 
sein im ausser sich sein.” This cri- 
minal vague way of expressing himself 
exasperated my yet unspoiled nature 
to such an extent that the same profes- 
sor never saw me again. 
In order to show howr minutely the 
differences of those diseases of which 
we know nothing are being defined, I 
need only mention neurasthenia and 
spinal irritation, between which I was 
never able to make a clinical distinction, 
because both are based upon the same 
pathological anatomical changes of the 
tissues. The same is the case with 
nearly all the various kinds of diseases 
which are labeled hysteria. When, a 
long time ago, Sydenham (I believe) 
introduced the designation of hysteria, 4 
he surely had no idea that this nam- 
ing; would cause more bloodshed and 
torture than perhaps Torquemada’s 
Inquisition, the local treatment, and 
afterwards the coronation of it, the 
wholesale castration for a disease, the 
origin, of which we are entirely igno- 
rant of. The cloak of science covers a 
good deal, but this chapter is the sad- 
dest one, for it treats of really crimi- 
nal remediation. This surgical side 
of the treatment of hysteria is not less 
criminal than the medical, for where 
the one castrates, the other renders 
insane. Fact, gentlemen! If a so- 
called hysterical person consults you, 
you look at her at first with a certain 
sublime disdain, which is only moder- 
ated by the expectation of the fee. 
You notice then that this patient looks 
not only very well, but somelimes 
even is a picture of bodily health, and 
this woman narrates a Jeremiah’s 
lamentation, compared to which the 
Miserere of Trovatore is merely a 
song. She tells you of disagreeable 
sensations and often of frantic pains, 
which exacerbate in irregular inter- 
vals and render life a burden. You 
inquire of the patient regarding cla- 
vus and glolxis hyst.; and, surprised 
by your profound knowledge, the pa- 
tient acknowledges she suffers from it. 
She leaves the office with a prescrip- 
tion and with the impression that you 
do not believe her. Probably you 
tell her husband, shrugging your 
shoulders, when you meet him, that 
he may feel easy about his wife, that 
she suffers from hysteria, all imagin- 
ary symptoms without pathological 
causes, which is particularly interest- 
ing, if there is a case of paralysis. 
The woman sees herself treated as a 
malade imaginaire by her nearest 
relations, nevertheless suffering with- 
out being able to cure her pains 
by imagination, on account of her 
physician's ignorance. But these 
doubts of her honesty, which are 
pronounced with such assurance, are 
only too apt to exert a detrimental in- 
fluence upon her state of mind which 
you would call hysterical psychosis. 
That commences perhaps by the pa- 
tient exaggerating her sufferings with 
the purpose of causing her affliction 
to be believed in until she really be- 
lieves in her imagination. No, there 
is a hysteria rightfully, and on an 
easily established basis, too, and the 
reason that the pathological basis has 
not been found before, is very simple. 
Hysterical as well as chronic rheu- 
matic patients usually die of other 
diseases, but in a post-mortem, only 
the interest in the direct cause of the 
death dominates the situation, as 
Manteuffel well remarks {Berl. Kl. 
Woch., 1873, p. 176). Another in- 
stigating circumstance for our former 
inactivity and subsequent ignorance 
is that hysteria and chronic rheu- 
matism are based upon a perturbation 
of the lymph system. But the lymph 
has caused so many obstacles to the 
investigation, especially in cadavere, 
that we must feel highly satisfied that 
we have been at last enlightened 
through the studies of Drs. A. Schmidt, 
Pekelharing, Lilienfeld, etc. 
1 invite you to discuss the following 
points with me: 
1. Various causes, too rich food and 
correspondingly insufficient exercise, 
local influence of cold, injuries, can 
produce a stagnation in the lymph 
system, which is principally confined 
to the lymph spaces. The lymph fis- 
sures become extended by this en- 
gorgement, and the Grawitz dormant 
cells provoke a small cellular hyper- 
trophy of the intestinal tissue with de- 
position of fibrine. This process is 5 
first noticed between the muscle fi- 
brillse and the terminations of the 
nerves. This not entirely stopped but 
retarded flow of lymph causes the nu- 
tritive fluid which surrounds the pa- 
renchyma of muscle and nerve to be 
insufficiently renewed, thereby be- 
coming exhausted. This causes a fa- 
tigue of the parenchyma, but is not 
sufficient to create total degeneration. 
This same disturbance of the nutrition 
can take place in the brain or spinal 
cord. It is analogous to the interstitial 
hyperplasia of our large glands, with 
the single difference that in the latter 
the parenchyma will in time be de- 
stroyed. 
2. This nutritive disturbance of the 
parenchyma causes the symptoms of 
chronic rheumatism, hysteria, trau- 
matic neurosis, neurasthenia and neu- 
ralgia, muscular rheumatism, so-called 
interstitial myositis and multiple neu- 
ritis. 
3. The changes produced are proba- 
bly of a chemical, not bacterial nature. 
The phenomena of the interstitial 
disease of our large glands are known 
as hyperplasia of the connective tissue, 
with pressure upon the parenchyma. 
The parenchyma becomes destroyed 
by this pressure, and more still by the 
nutritive disturbance caused by the 
engorgement of the lymph canals; the 
nutritive tissue retracts, being de- 
prived of its physiological function, 
which consists in the separation or 
better isolation of the parenchyma 
elements in supplying them with nu- 
tritive fluid and in renewing the effete 
matter. I do not wish to mention 
here the toxico-chemical causes of 
these interstitial processes, but rather 
to accentuate this point, that with 
such patients there is always too rich 
a supply of food with too little com- 
bustion, caused by insufficient peri- 
staltic and voluntary motion. These 
circumstances, single or combined, 
then cause an engorgement of the 
concentrated lymph, which condition 
is first noticed in the fissures and 
tissue spaces, the source of the lymph 
system. 
Our treatment of these diseases 
proposes to remove by the reviving of 
the peristaltic motion the results of 
the engorged lymph. This is reached 
to a certain degree, as the aperients 
administered in the first stages of the 
disease give at once a passing relief. 
Why should these elementary path- 
ological conditions not be active out- 
side of our large cavities and intes- 
tines? We have everywhere the same 
anatomical physiological basis, pa- 
renchyma elements, which are sepa- 
rated from each other, nourished and 
drained by connective tissue, only 
that here the place of the paren- 
chyma is taken by muscle fibers and 
nervous tissue. We certainly have 
these engorgements just as well there 
as inside of the cavities, not only 
much more frequently, but more ex- 
tensively. The prototype of this 
process of small cellular infiltration 
and deposit of fibrine is found in any 
contusion; the same has been proved 
for the so-called chronic interstitial 
myositis, accompanied by rheumatic 
swellings. The only hypothesis 
which I make use of here consists in 
the conjecture that the same nutritive 
perturbation can and must be sup- 
posed to exist, for the peripheral nerve 
terminations there, as where it has 
been already proved, for the muscle 
fibrillse, we cannot logically separate 
them from each other. The flow of 
lymph in our intestines does not sur- 
mount the same obstacles as in the 
trunk or the extremities. We have 
three continual motors in our large 6 
cavities which are independent of our 
will-power— circulation, respiration 
and peristalsis—which exert a perma- 
nent influence upon the motion of the 
lymph. Respiration and peristalsis 
operate upon the centripetal motion 
of the lymph by aspiration. Each 
motion of the diaphragm calls for an 
expansion of the thorax, the same 
contraction of the diaphragm com- 
municating itself coinciclently to the 
stomach presses upon its volume, the 
walls of the stomach contract, for- 
ward its contents and the peristalsis 
moves on quietly and permanently to 
the anus. The third motor in our 
body is the heart. It has very little 
to do with the flow of the lymph. 
The passage of the plasma through 
the stomata of the blood capillaries 
to the fissures of the connective tissue 
must be regarded as a product of se- 
cretion of the cells of the blood cap- 
illaries (Heidenhain). 
This motion is in part a filtrating 
pressure, but is principally cared for 
and upheld by the amoeboid motion of 
the leucocytes (Cohnheim). This 
plasma keeps up the nutrition of the 
tissues from these fissures, wherefrom 
the necessary nutritive substances are 
selected by the tissues. The effete 
matter is led back to the fissures and 
is conducted to the lymph capillaries, 
which forward them to the venous 
ways (Landois). 
The elastic fiber which takes the 
place of the amoeboid motion of the 
leucocytes at the beginning of the 
lymph capillaries, and furthermore 
the horror vacui, forward the lymph 
to the cavities of the abdomen and 
chest. It, therefore, evidently takes 
very little to stop this very feeble 
current of the lymph from the blood 
capillaries to the lymph capillaries, 
be it, for instance, in the large cavi- 
ties a retarding of the peristalsis as it 
happens in habitual constipation, or 
outside of the intestinal cavities in- 
sufficient exercise of the muscle. 
Such a chronic engorgement of the 
lymph current has the following con- 
sequences: the sluggishness or com- 
plete stoppage of the passage of the 
lymph extends back to the fissures, 
the effete matter of the parenchyma- 
tous tissue cannot be carried off to 
the kidneys to be removed, but ac- 
cumulates around the elements of the 
muscle and nerve parenchyma; in- 
stead of furnishing nutritive fluid for 
the parenchyma this fluid becomes 
exhausted and the parenchyma suffers 
from an intense disturbance of its 
nutrition, which can reach exhaustion, 
though hardly results in complete de- 
generation. But this chronic nutri- 
tive disturbance suffices to injure their 
function in a high degree. 
This nutritive disturbance is one 
important consequence of the en- 
gorgement of the lymph. 
B. Grawitz has demonstrated that 
in all progressive disturbances of nu- 
trition not only the fixed corpuscles 
of the connective tissue become active, 
but his dormant cells awaken from 
their “sleeping-beauty” condition, 
turn mobile, and a small cellular in- 
filtration is established before a leuco- 
cyte immigrates. This infiltration is 
soon augmented by the presence of 
fibrine. How does that come to pass? 
Excessive active (as with the moun- 
tain disease) and passive motions 
thicken the blood; want of exercise 
thickens the lymph. The blood adds in 
its capacity of a supply current, albu- 
minates, fats, salts, carbohydrates to 
the tissues; the lymph brings the excre- 
mentitious products, urea, C O', IT O, 
and salts to the secreting organs. 
This effete matter returns, if these 7 
secreting organs are not competent 
for removal. Patients of this kind 
not only suffer from want of exercise 
but they add more food to the blood 
than it is able to accommodate, con- 
sequently the concentration of the 
lymph is being favored and we have 
a plethora hyperalbuminosa. But 
that does not suffice for the explana- 
tion of the deposition of fibrine 
from the plasma. We know that 
fibrine precipitates on the degener- 
ated* walls of bloodvessels. That 
may be the case here, as the 
fissures and capillaries filled up 
with the small cellular infiltration may 
be regarded as such. A. Schmidt has 
demonstrated that there are changes 
in the blood; real diseases of the 
blood, in which the physiological ex- 
change of the white blood corpuscles 
seems to be exceedingly increased, 
and the products of the circulation 
accumulate in the blood. The conse- 
quence is, of course, the appearance 
of spontaneous coagulation within the 
organs of circulation. The supposi- 
tion is not unwarranted, that the 
same is the case with the lymph, at 
least I wish to explain in that way the 
formation of lymphangitis which is 
often noticed in chronic rheumatism 
and which causes, usually, an increase 
of temperature. 
According to Schmidt, the ferments 
which cause the precipitation of the 
fibrinogen, are already in the blood. 
We find with each increased hyper- 
plasia within the connective tissue an 
increased dissolution of leucocytes 
which raises considerably the con- 
tents of fibrine in the lymph. In 
consequence of the dying oft’ of leu- 
cocytes which give oft' nucleo-albumi- 
nates to the plasma, these nucleo-al- 
buminates join the carbonate salts of 
the plasma and act in this connection 
as ferments. 
According to Lilienfeld, the leuco- 
cytes contain a substance, the nucleo- 
histon, which can be split into nuclein 
and a coagulable albuminate—the his- 
ton. This nucleo-histon possesses the 
important quality to keep the blood- 
11 uid, if introduced into the circula- 
tion, or added to the blood gotten by 
venesection. On the other hand, the 
coagulation of the blood is an effect of 
the leucocytes, especially of the nu- 
clein, which is contained in them. 
Both substances, the coagulation- 
causing and coagulation-preventing, 
are connected with each other in the 
nucleo-histon. The so-called liisto- 
plasma, which remains fluid after the 
addition of nucleo histon, becomes co- 
agulated, nucleo-histon derived from 
leucocytes, is added, even if the nu- 
clein solution has been boiled. If one 
adds a nucleo-histon solution to a 
fibrinogen solution, there will be no 
coagulation until after addition of a dis- 
solved carbonate salt. Thus the car- 
bonate salts confer upon the nucleo-his- 
ton coagulation-causing qualities, and 
the fluid condition of the blood is tied 
to the chemical presence of nucleo- 
histon, but each time nuclein will be 
made free if the substance splits, and 
will become coagulation-causing. 
In the same manner Pekelharing 
finds that the fibrine ferment is a 
nrtnniiMtr combination which is able 
to confer ca-sJswwite upon fibrinogen 
and thus to produce from the soluble li- 
brinogen an insoluble caTteowrte hold- 
ing an albuminous body.* 
*A. Schmidt, Zur Blutlehre, Leipzig, 1892.— 
L. Lilienfeld, Haematolog. Untersuchungen, 
Aichiv. f. Physiol., bei Dubois-Raymond, 
1892.—A. G. Wright. The Lancet, 1892.—V. A. 
Pekelharing. Die Bedeutung der Kalksalze 
fuer die Gerinnung des Blutes, Virchow’s 
Festschrift, 1892. — Hammerstein, Green, 
Rossel, etc. 8 
Another cause for coagulation of 
the lymph is the influence of cold. 
Thrombi originate interstitial hyper- 
plasias, which are caused probably by 
the increased destruction of cellular 
elements in the much refrigerated 
blood (Landois). Or these cellular 
elements with fibrine attach them- 
selves to the walls of the lymph-ves- 
sels and cause a lymphangitis which 
is often noticed with rheumatism. 
After having seen how fibrine may 
be precipitated we must follow up its 
further behavior. Restitutio ad in- 
tegnun can take place if this formation 
of fibrine soon ceases; but if some time 
passes before that takes place we 
will have subsequent precipitations at 
other places, the older ones getting 
dryer, hard, by absorption of the gel- 
atinous plasma, the small cellular 
infiltration continuously disappears 
and a more or less organized sub- 
stance is formed, similar to cicatrized 
tissue. Since there is not much space 
for expansion in the intraparenchy- 
matous tissue the fibrine connects the 
various muscle fibrilke with each 
other. The same process probably 
takes place within the nerves when 
partial hyperplasia of the neuroglia 
causes pseudo-neuromata to develop, 
as I observed once, in great num- 
bers on the nerve cruralis. In time 
the afflicted muscles become harder, 
shrink, but never atrophy completely 
to my knowledge. Such muscles 
feel, if you palpate them with a 
moist finger, uneven, but transversely 
ribbed. 
Of more importance in their influence 
upon the function, by connecting the 
tissues, are the precipitations of fibrine 
between muscles, nerves, faeise, ves- 
sels, bones and mucous pockets. They 
occur very often and may reach the 
size of a halved goose egg underneath 
the muscle. They cannot be shifted 
from the femur and seem to be situated 
directly upon the periosteum. These 
swellings feel elastic where they are 
superficial and often simulate fluctua- 
tion, but seldom are cedematous. They 
reach their largest size underneath the 
tendons because probably the motion 
of the body of the muscle hinders 
their expansion. If located between 
muscles it is natural that these swell- 
ings exert an extremely disturbing: 
effect by their pressure upon n(*rves, 
muscles and vessels. Their most dele- 
terious effect is developed by their 
connecting all surrounding tissues, so 
much so that, for instance, the mus- 
cles of the thigh cannot be distin- 
guished or separated. It is evident 
that the skin and the subcutaneous 
tissue which have no contractile prop- 
erty are attacked first. The skin there- 
fore is so closely attached to the 
underlying muscles that it can abso- 
lutely not be raised infolds. If now, 
for instance, such patient desires to 
extend his leg, its stretched muscles 
are fastened to their antagonists, the 
flexor muscles must be moved with 
them. The motion pulls the adhesion 
of the antagonists, causes therefore 
pain, and at the same time the in- 
tended motion is poorly, slowly and im- 
perfectly executed. The more the 
adhesion of the antagonistic muscles 
increases, the more insecure and defi- 
cient will be the motions, until at last 
complete invalidism results. Where 
these swellings are undisturbed, as 
underneath the tendo Achillis, they 
will ossify and form Virchow’s hyper- 
plastic osteomatas. These ossifications 
can occur anywhere with increasing 
invalidism; they have for many years 
been recognized. It is the interstitial 
tissue out of which the bone grows. 
Wherever there is interstitial tissue, 9 
bone may develop in the neurolemma, 
periosteum, etc.* 
These hyperplastic osteomata are 
especially noticed on the extremities. 
They can only be considered as ex- 
ostoses after Virchow, as an exostosis 
is a hyperplasia of osseous substances 
of a normally existing bone. Unfor- 
tunately Virchow’s original treatise is 
not at my disposal and I make refer- 
ence here to Dr. Kreiss, Primare 
Schwielige Myositis, No. 51, Berl. 
Klin. Woch., 1S86. 
Dr. Kreiss’s observation of the 
formation of these ossifications har- 
monizes completely with my view and 
experience of the influence of the at- 
mospherical conditions upon the for- 
mation of these indurations, and I am 
corroborated by the anatomical re- 
searches of Mays, who says that the 
pathological process takes its start 
from the interstitial tissue, the ten- 
dons, fasciae, the intermuscular con- 
nective tissue, the periosteum; in fact, 
the seat of these ossifications extends 
far over the muscular system. Vir- 
chow says that the subcutaneous tis- 
sue is not liable to be involved or 
affected by this process. This, how- 
ever, is only true in regard to the 
production of osteomata. I never 
saw such in the subcutaneous tissue, 
still the hyperplasia takes place there 
too and can accordingly, theoretically, 
lead to ossification. 
In the bloodvessels there are less 
disturbances, more, however, in the 
nerves. We can have all possible 
anaesthesia, hypersesthesia, absence or 
increase of reflexes; all the symptoms 
of pressure, including strangulation, 
occur in connection with defec- 
tive nutrition of the nervous pa- 
renchyma, through engorgement of 
the nutritive plasma. It is certain 
that the latter cause is far 
the more frequent. Pressure upon 
the nerves usually involves pressure 
upon the near arteries and veins. I 
have found only one mention of ab- 
sence of the arterial pulse in litera- 
ture. (Edema is not often noticed, 
and I never saw engorged veins or 
varices which would result therefrom. 
So the parenchymatous disturbance 
of the nutrition remains the principal 
circumstance. I wish to accentuate 
here that the more I recapitulate my 
cases the more I feel convinced that 
the brain nerves are relatively seldom 
involved; that it is mostly, with 
few exceptions, the spinal nerves 
down to nerve coccygis. If there are 
neuroses of the brain nerves or nerve 
sympatheticus, they are originally 
caused by irradiation. The symp- 
toms of the brain, if they are really 
caused there, are to be attributed to 
the nutritive perturbations which are 
caused by the pressure of indurative 
swellings of the neck upon the lymph 
canals passing down from the brain. 
Fatigue, with temporary narrowing 
of the field of vision, of neuras- 
thenia, must be supposed to be based 
upon engorgement of the lymph 
canals in the cortex of the occipital 
lobe. They behave exactly as they 
do in the muscles, nerves, etc., of the 
trunk and extremities; that is, the 
perturbation of the nutrition is not 
severe enough to leave a fatty degen- 
eration of the nerve elements and to 
render possible a pathological ana- 
tomical preparation, but they are im- 
portant enough to cause a considerable 
restriction of the function. 
Now about the joints, I can only 
mention my experience, but that 
teaches me that the chronic rheumat- 
ism of the synovial membrane is ex- 
ceedingly rare. The appendices, liga- 
*Koester, Berl. Klin. Woch.. p. 187, 1893. 10 
monts are usually afflicted, the mu- 
cous pockets are much swollen, but the 
joint proper is seldom the seat of this 
affliction, and if it is, then acute 
rheumatism has preceded it, or a 
scrofulous diathesis is present, which 
is elsewhere exhibited. 
The ligaments are far more suscepti- 
ble, and also the periosteum, and I 
especially mention the tibia, the out- 
side of the caleaneum, femur, hume- 
rus, a few places of the skull, and the 
sacrum. The cellular hyperplasia of 
the periosteum imparts a particularly 
velvet-like sensation to the finger. 
The lymph canals exhibit an inter- 
esting phenomenon. They thicken by 
precipitation of fibrine in a centripetal 
direction, they are easily felt as hard 
round strings of varying thickness, 
often interrupted by nodules or pro- 
tuberances like a rosary. Usually, 
after some imprudence or exposure, a 
little increase of temperature sets in, 
excessive, objective and subjective 
painfulncss demonstrates the area of a 
lymphangitis on an extremity or the 
neck, but hardly where there are not 
some fibrine deposits in the periphery. 
By and by the soreness leaves, and 
perhaps the strings too. Ordinarily it 
remains, collateral lymph-ways form 
and fill up again and so on, until 
whole tumors of such accumulations 
of obliterated lymph canals are es- 
tablished, as it is especially in the case 
of fat women, on the inside of the 
knee, on the adductors, and outside 
of the trochanters. A like condition 
results upon the region from the hi}) 
bone to the loins and on the angle of 
the pectoralis major with the hume- 
rus. So we have the acute closing up 
of a lymph-canal by the formation of 
thrombus several inches in length, 
from acute feverish lymphangitis, and 
the chronic gradual narrowing of the 
lymph-canal’s lumen by successive 
precipitation of fibrine. The latter 
process is the rule, and explains the 
objective and subjective feeling of 
coldness in the limbs of such patients, 
as the nutritive fluid is not often and 
thoroughly enough renovated. 
The influence of the weather upon 
rheumatic diseases is known by the 
popular name “ The Rheumatic Bar- 
ometer.” I made observations for a 
full year and found that the tempera- 
ture has little influence if the patient 
can protect himself from local influ- 
ences of the cold by proper clothing. 
But as soon as the barometer fell and 
the humidity of the air reached a cer- 
tain degree, I heard from my first 
visit in the morning until late at night 
everywhe re the same lamentation, 
neuralgias, nervous feeling, etc. This 
harmonizes with the paroxysmal char- 
acter of neuralgia, hemicranias, neu- 
rasthenias, etc. I wish to state in 
explanation of this phenomenon the 
following: 
Our body, with all its tissues, is 
hygroscopic. If the woather is nice, 
the air dry, we give oft' considerable 
water to the air, and thereby our tis- 
sues and the whole body will shrink. 
As soon as the barometer drops and 
the humidity of the air reaches a cer- 
tain degree, the body gives off no 
water to the air, and all our tissues 
swell up. Everybody has had this 
experience with tight shoes, which he 
can put on very well in good weather, 
but hardly in bad weather. Upon 
this swelling of the tissues, too, is based 
the depressed or blue feeling of other- 
wise healthy persons, the flow of the 
lymph oft the brain is retarded, the 
brain parenchyma hungers and its 
function is lowered. Now, the rheu- 
matic indurated or Froriep’s swelling 
is subjected to the same laws. With 11 
increasing humidity of the air they 
swell and press upon the nerves, if 
such are near. There are very few 
exceptions to this rule, and these are 
based upon the location and shape of 
the swelling. 
A very marked influence is exerted 
by an air which is charged with elec- 
tricity, as before great storms. It 
incites rheumatics to the climax of 
pains and nervousness. It is aston- 
ishing, indeed, that the atmospheric 
perturbation can be thousands of miles 
away and still exert its influence. At 
the beginning of last September we 
had a terrible storm which came 
up from the West India Islands all 
along our Atlantic sea-coast and cost 
more than a thousand lives. Here, in 
St. Louis, we only felt a change of 
temperature, with beautiful dry 
weather, but several of my patients 
felt the perturbation just as if the 
storm had reached here. That is all 
the explanation I can give at present 
of this unsolved puzzle. 
The appearance of these deposits 
of fibrine in our body is nearly al- 
ways symmetrical, usually more ac- 
centuated on one side of the body, 
which is perhaps in connection with 
the innate and educated predominance 
of one-half of the body. 
They are always in the same 
places, evidently loci minoris resis- 
tentice, which are afflicted. The ques- 
tion will certainly be advanced, 
whether or not these deposits of 
fibrine are due to parasitic influences. 
I could find nothing, and hardly be- 
lieve that ever anything will be found 
because the whole process is of a 
chemical-physical nature. We have 
the same process in each injury; 
for instance, the fracture of a leg, 
not only the lymph canals of the 
periosteum, those of all the fleshy 
parts in the line of the fracture are 
lacerated and contused. We see the 
formation of the same small cellular 
infiltration and deposits of fibrine 
which glue the concerned tissues to- 
gether, and it takes often months 
after the callus has formed till the 
whole circulation is established again. 
But for a long time to come these pa- 
tients complain about rheumatic pains 
in the fractured leg, especially if the 
weather changes. This process is a 
prototype of a traumatic neurosis. 
We cannot suppose that a parasite 
put up its wigmam there. Further, 
we would expect that certainly the 
lymphatic glands would be swollen 
in an affliction like this, where 
only the lymph is perturbed like it is 
in syphilis, tuberculosis, carcinoma, 
etc., but I never noticed a swollen 
gland, and the bodies, which might 
be regarded as such, always proved 
to be rheumatic swellings and were in 
unusual places. 
THE EXAMINATION IS OFTEN DIFFICULT. 
L. Eaver* evidently is on the right 
line, and I agree with everything 
which he says in his meritorious ar- 
ticle on rheumatic swellings. 
Eaver says whoever thoroughly ex- 
amines, that is, feels the muscle by 
pressing it against its underlying base, 
or tries to separate it from the bone, 
and then follows it up with hard pres- 
sure from the head to the tendon of the 
muscle, will be astonished how often the 
consistency of the muscle is different in 
different places. One finds either the 
whole muscle transformed into a hard, 
tough string, or only so in a few 
places; on other places there are 
swellings from the size of a pea to 
that of a walnut. These changes are 
found either single or there are hun- 
dreds of them in one individual. Per- 
* No. 9, Seri. Kl. Woch.,im. 12 
sons who have swellings in their mus- 
cles present thickened patches upon 
the skin, excessively painful upon 
pressure. The skin swellings feel pe- 
culiar, and when one rubs them it 
seems as if there were several sheets 
of moist sheepskin between the hands. 
T have often noticed this slipping sen- 
sation and would add that it appears 
more like an unevenly ribbed body. 
I wish to mention another important 
point about the examination. The 
lines of the muscles and along the basis, 
if straight or in a curve, present always 
an uninterrupted line; as soon as the 
gliding finger feels even a slight inter- 
rupt ion of this line, or a protuberance, 
we can be sure that this is diseased. 
To find swellings in the depth, under 
the glutaii muscle, or the pelvis, we 
must press very hard and equally, and 
make our observation with a gliding 
down motion. Any morbid change 
will be noticed at once and painfully 
by the patient. This pain is described 
as being different from the sensation 
felt in normal tissue. This pain is 
caused by the tearing of the numerous 
adhesions. Healthy tissue never feels 
painful by hard, but even, pressure. 
It takes much experience and inde- 
fatigableness to easily find the places 
where hyperplasias are likely to exist 
and if a close examination does not 
unveil any positive result it must be 
repeated, especially if the disease 
gives rise to suspicion of hyperplasias. 
One may be sure of the points sooner 
or later. Special advice about investi- 
gation follows later under the treat- 
ment of the single parts of the body. 
We nowT arrive at the different 
hinds of diseases which form the path- 
ological manifestation of this hyper- 
plasia of the connective tissue and of 
the engorgement of the lymph. 
To escape misinterpretation I wish 
to state right here, that the acute 
rheumatism, which originates upon a 
parasitic basis, is only related to 
chronic rheumatism in that it very 
often leaves engorgement of the lymph 
system, which increasing predisposes 
to chronic rheumatism, but only after 
the acute process has ceased. Chronic 
rheumatism has feverish exacerba- 
tions only, if mild or severe lymphan- 
gitis augments an attack, and then 
often with a hardly perceptible rise 
of the temperature. The acute rheu- 
matism is in the same causal relation to 
the chronic as gout (arthritis uraei). 
The widespread view that the chronic 
rheumatism belongs to the uric dia- 
thesis is completely falsh and obso- 
lete, as uric acid is not produced in 
greater amounts than in other dis- 
eases. Even if we regard fibrine as 
a basis of the urine, it has nothing to 
do with the secretion of uric acid. 
Just as untenable is the expression so 
often used in England and in this 
country, “rheumatic gout,” it re- 
mains all the same, whether one ad- 
heres to Garrod’s theory about gout, 
or inclines to Ebstein’s clear exposi- 
tion ; for if chronic rheumatism ever 
complicates gout, it is found there be- 
cause the local necrosis of the tissue 
irritates the connective tissue to hy- 
pertrophy. The chronic rheumatism 
is there in the same relation to gout, 
as it is to a fracture of a leg. The 
expression rheumatic gout is caused 
by the confusion of the view which 
places both diseases upon the uric acid 
diathesis. 
HYSTERIA AND THE HYPERPLASIA OF 
THE CONNECTIVE TISSUE. 
If I were a candidate and asked, 
what is hysteria, I would answer: 
“Whatever is not subject to ordinary 
rules is considered hysterical.” I can 
really not understand how, after hav- 13 
ing perused for eight years the Berl. 
Klin. Woch., and other literature, no- 
body has made use of the local patho- 
logical symptoms (not of the sexual 
organs) which are mentioned so often 
in the literature of the subject. 
Leyden correctly says: “ It is nowa- 
days one of the most important and 
difficult problems to decide how far a 
local disease influences the whole or- 
ganism, or the reverse; how far a 
thorough affliction of an organism pro- 
duces a local disease or influences it.” 
I wish to add to these words, that 
we ought above all and always to 
trace back a disease to a pathological 
change of the local anatomy, and if 
we cannot locate this change, where 
we suspected it, we must look for it 
elsewhere and not commit ourselves 
to the cheap substitute of speculation. 
After the local affliction of female 
sexual organs as the principal cause 
of hysteria has become untenable, we 
must omit the expression “hysteria” 
entirely, as convenient and beloved as 
it is. We always see the endeavor 
to transmit the cause of the hysterical 
symptoms to the central nervous 
system, though the result of the post- 
mortems is totally negative. One 
says, hysteria is based upon imagina- 
tion. Do not even physicians imagine 
all possible exotic diseases if some- 
thing ails them, notwithstanding their 
knowledge? Is imagination really 
morbid,for instance, with a child when 
playing? Then only idiots and stupid 
ones are healthy, for each man suffers 
from imagination and it is really only 
imagination which makes life worth 
living. 
Another appeals to the Psyche; 
calls it psychosis. That appears to 
me almost like the answer of the can- 
didate who, being asked how are we 
made aware of the actus visus when 
the image has been reflected reversed 
upon the retina, answered: “Yes, 
back of the eye there is the soul, 
which turns the image.” 
I sometimes think that our neuro- 
logical colleagues have one foot in the 
suggestive theory of Christian sci- 
ence; the other foot, I do not know 
where, surely not in Virchow’s cel- 
lular pathology; perhaps in the largely 
propagated philosophy of the un- 
known. If there are individuals whose 
cells of personal will-power can be 
disconnected from the masse battery 
of the brain by suggestion, then 
there may be such whose cells of sen- 
sibility can be disconnected. That 
does not imply, though, that we can 
remove a chronic engorgement of the 
lymph with small cellular hyper- 
plasia and deposit of fibrine within 
reach of peripheral nerves by sug- 
gestion; or, in other words, that we are 
able to cure a single pathological 
cell by suggestion. 
I do not speak here of that hysteria 
which might be rather called educated 
naughtiness, and does not belong to 
the sphere of the physician, but I in- 
clude all other hysterical symptoms, 
if I say that they are caused by defec- 
tive nutrition (or perhaps pressure up- 
on) of the spinal nerves caused by hy- 
perplasia of connective tissue and en- 
gorgement of the l}rmph. They are 
caused either directly by the spinal 
nerves or communicated by their anas- 
tomoses with the nervus sympathicus 
and the brain nerves by irradiation. 
Those symptoms of the brain and 
spinal cord which appear in the course 
of a hysteria, and cannot be attributed 
to irradiation, are caused by the same 
parenchymatous nutritive disturbance 
of the central nervous system. If an 
exact history were taken of all the 
women which are received in the hos- 14 
pitals for perhaps a fatal disease, if 
the neuralgic, hysteric, rheumatic, 
etc., symptoms of which they for- 
merly suffered were exactly noted and 
the corresponding painful points of 
swellings in life-time considered, we 
should soon be in possession of more 
supplementing facts. 
In order to show that neurasthenia 
and spinal irritation owe their ap- 
pearance to the same phenomena, I 
will briefly discuss the traumatic 
neurosis. 
First it was called “ railway spine” 
and one investigator* distinguishes, as 
in German railroad coaches, three 
classes of traumatic neurosis. Here a 
case recurs to my mind which I had 
years ago. 
A railroad official went one Sunday 
morning after breakfast to read his 
paper where many others read it. 
Suddenly his seat gave way and he 
fell with it, dans le consonimiee, as it 
is called in French. He injured the 
muscles of his back and I treated him 
for neurasthenia. It was not railway 
spine, though he was a railroad man. 
Could I call it on account of the cir- 
cumstances ‘ ‘ water-closet spine? ” It 
is evident that railroad men are ex- 
posed to more contusions of the mus- 
cles than others, but not all wounded 
railroad men turn neurotic or 
asthenic from it. I had the same ex- 
perience with soldiers who were near 
an exploding shell and without having 
received any visible injury or con- 
tusion, suffered intensely from shock. 
It is probable that powerful concus- 
sion, fright (fire), etc., increase first 
the function immensely, but after- 
wards exert a very exhausting influ- 
ence upon our nervous system, being 
comparable to a telephone box which 
was struck by lightning and burnt out. 
I do not think it necessary to name 
these phenomena particularly. I ad- 
mit that sudden or lasting great de- 
mands upon our thinking, feeling or 
will-power may cause identical condi- 
tions in the parenchyma of our peri- 
plierical or central nervous system as 
any injury does, or any engorgement 
of the lymph from other causes. The 
organ incited suddenly to the highest 
capability surrounds itself with more 
effete matter than can be removed by 
ordinary conditions, and the com- 
mencement of a chronic engorgement 
of the lymph occurs. The many ac- 
cidents from false switching, for in- 
stance, are caused by too long work- 
ing hours and fatigue of our central 
nervous system. We have the “in- 
sufficiency of the higher nerve cen- 
ters against functional overloading” 
(Friedman). 
The traumatic neurosis is other- 
wise a very good expression. Roth 
says about it: “In the first class, 
the typical railway brain, objective 
symptoms can be entirely absent. 
We notice besides the well-known 
neurasthenia, irritative symptoms, 
vague pains in various parts of the 
body. They are most pronounced 
along the vertebral column.” 
If Roth had examined well he would 
have found certain points which can 
be separated pretty well from the 
tissue, in which they are imbedded 
and which cause unbearable pain upon 
hard pressure. I think these are ob- 
jective symptoms. 
Those who travel second class have 
“painful sensations in various parts 
of the body besides increased irri- 
tability,” as above and functional 
disturbances of the Psyche. Roth 
mentions the hysteric stigmata, 
hemianesthesia and functional dis- 
turbance of the sensory nerves, re- 
*G. Roth, No. 9, Bcrl. Kl. Wool)., 1891. 15 
trenchment of the field gf vision, 
without patients complaining of it. In 
the third class pure functional neuroses 
combine with organic changes of the 
brain and the cord. He cites two 
cases of traumatic neurosis upon 
which a post-mortem had been made 
and which exhibited arterio-sclerosis 
with spotted white degeneration of 
the mcdul lated nerve fibers of the 
trunk of the nerve sympathicus. 
I will demonstrate later that all 
these symptoms of traumatic neu- 
rosis are identical with those of 
chronic rheumatism. If I knock my 
elbow against something, there will 
result for several minutes a numbness 
of the ulnar side of the forearm and 
hand, and I feel perhaps sick at the 
stomach from irradiation of the nerve 
vagus. Roth will notice, if he inves- 
tigates, that these painful places along 
the vertebral column pass to the atlas, 
and that such patients suffer from dis- 
turbances of the sense of taste. I have 
at present a patient who with each 
rheumatic attack is afflicted with an 
eruption of blisters on the lower edge 
of his tongue and soft palate. He has 
on the same side a rheumatic paresis 
of the nerve facialis. For a long 
time I took these for dyspeptic symp- 
toms, but stomach and nutrition were 
always in first-class order. About the 
psychical symptoms I expressed my- 
self above. 
The third class where there are pos- 
itive pathological changes in the spinal 
cord and brain, does not belong here. 
Traumatic neuroses are seldom di- 
rectly connected with brain or spinal 
cord. I can say so pretty decidedly, 
for I never saw a case of traumatic 
neurosis which could not be cured, 
because the affliction was peripherical 
and could be reached by local treat- 
ment. Where it a lesion, a real 
pathological change of the brain or 
spinal cord the prognosis would prob- 
ably be worse. The two cases which 
showed arterio-sclerosis at the post- 
mortem certainly do not belong to 
traumatic neurosis. I will admit that 
an artery can turn sclerotic by a 
trauma at the place where the trauma 
took effect, but this sclerosis does not 
go on and causes no perturbations. 
Of course we can have diseases of 
brain and cord which present symp- 
toms similar to traumatic neurosis or 
neurasthenia, but these are afflictions 
of the central nerve system, and not 
traumatic “homeless” neuroses. We 
can be sure to find with almost all so- 
called traumatic neuroses painful 
points, and if we do not find them after 
repeated careful examination and hard 
massage all over the body, then only 
may we think of brain and cord. I 
never found a clinical difference be- 
tween traumatic neurosis and neuras- 
thenia, and cannot find any among 
the described cases. Sometimes a 
trauma gives the starting point, or, 
what is more probable, an already ex- 
isting but latent stasis of the lymph 
system is more accentuated by a 
trauma. Sometimes we see the same 
pathological condition without acci- 
dental trauma, and if any one can 
show me a real difference between 
neurasthenia and spinal irritation, for 
instance in Erb’s description, then I 
yield. It looks to me as if one would 
distinguish between three dyed-in-the- 
wool niggers by calling them black, 
raven and real black. 
At last thv polyneuritis, or multiple 
neuritis, which distinguishes itself by 
really being no neuritis at all in the 
true meaning of the word, Eisenlohr* 
demonstrated, in nine cases, that in 
no case the localization of the para. 
* Berl. Kl. Woch., No. 42, 1889. 16 
lysis corresponded with one or sev- 
eral nerves. In bad cases all muscles 
of the extremities seemed paralyzed. 
The affection presented itself, without 
exception, symmetrically distributed 
over the muscle groups of both sides. 
In bad cases the trunk muscles too, 
rarely those of the neck, were afflicted. 
Brain nerves are intact and never 
complicated with psychical symp- 
toms. Reflexes of patella in seven 
cases extinguished, in two reduced 
but returned. Eisenlohr’s fdescrip- 
tion is identical with the one I give 
for chronic rheumatism. The dissec- 
tion of a case showed spinal and ante- 
rior roots intact and extended paren- 
chymatous degeneration of skin and 
muscle nerves. This affection is not 
to be mistaken for acute feverish 
polymyositis, which shows hyaline de- 
generation of the muscle parenchyma 
not of the connective tissue * or the 
myxoedema, which I unfortunately do 
not know by my own experience. 
The pathological cause of polyneuri- 
tis is the same as that of hysteria, 
traumatic neurosis, chronic rheuma- 
tism, a disturbance of the nutrition of 
the termination of the nerves, with the 
sole difference that the affliction ex- 
tends over the whole body and is 
more grave, with a predominance per- 
haps of the neuralgic character. 
Only the neuritis nodosa has claims 
to a real neuritis. The neuroglia of 
the diseased nerves is permeated with 
numerous nodules like a pearl string 
from hyperplasia of the connective 
tissue. Usually this kind is mixed up 
with the other perturbations. I only 
once saw a genuine case, as follows: 
A man thirty years years old suffered 
for three years from exceedingly vio- 
lent neuralgia inside of the right leg. 
Attacks appear regularly every 
*Paul Ilepp, 22 Berl.Kl. Woch., 1889. 
evening and patient walks the floor all 
night until morning. A surgeon made 
diagnosis of diseased hone, made 
incision, found nothing. Pains re- 
mained absent during healing of 
wound. Another surgeon pronounced 
it neuralgia, prescribed liniments with- 
out success. I found the whole dis- 
trict of the nerve cruralis intact, 
nerve cruralis resembled a rosary 
from knee up to Poupart’s ligament. 
After the first massage the patient 
could sleep well all night and felt 
after three more treatments no return 
for four years; but usually these 
pseudo-neuromata are very persistent. 
Now for a name for these diseases 
which have artificially been torn apart, 
though they exhibit the same patho- 
logical phenomena. We must deal with 
a rheuma, a real pure rheuma; we 
cannot find a better designation and 
one more to the point than that of 
chronic rheumatism. If one desires 
a classification he may distinguish: 
Chron. Idiopathic Rheumatism, 
Traumatic Rheumatism, 
Asthenic Rheumatism, 
but all caused by the s;ime lympho- 
stasis. 
THE SYMPTOMS OF THE HYPERPLASIA 
OF THE CONNECTIVE TISSUE ON THE 
DIFFERENT PARTS OF THE BODY. 
You have the choice of the symp- 
toms of neuralgia, neurasthenia, hys- 
teria and neuritis and will always find 
the same symptoms in an affliction of 
the same parts of the body. I wish 
especially to state here the paroxysmal 
appearance of these symptoms which 
always coincide with a cold (change of 
weather), pleasures of the table, men- 
struation, which so much influences 
the lymph or a local inflammation. 
We can almost always find so called 
painful points of pressure, especially 
along the course of the spinal nerves, 17 
and of the fifth and seventh cranial 
nerves. These points are spread over 
the whole roof of the skull. There 
are normally impressions on the skull 
which are not particularly painful on 
pressure, but if we have to do with a 
neurasthenic rheumatic, we feel round 
soft swellings which, on pressure, 
cause the most intense pain and hemi- 
cranias. This is common in women 
with heavy hair. Such points are on 
each side of the occiput above the 
parietal protuberance where the 
nerve occipitalis emerges and on 
the insertion of the muscle tempo- 
ralis. Larger parts of the aponeuro- 
sis may be painful, and in connection 
with it the muscles of the neck may 
be sensitive; usually there is more ac- 
centuation on one side of the verte- 
bral column than on the other. The 
ligaments between the processes spi- 
nosi show pain upon pressure. The 
skin of the neck is often connected 
with the underlying tissue. The angle 
of the jaw and the insertion of the 
masseters, the foramen supra and in- 
f ra-orbitale, the chin, the whole course 
of the carotid and the perichondrium 
of the larynx can be extremely sensi- 
tive down to the plexus brachialis and 
the feeling finger always finds on the 
painful places abnormal, particularly 
slippery swellings. The hemicranias 
are particularly cared for by the 
nerve occipitalis. Irradiations can be 
voluntarily provoked upon the nerve 
vagus. The peripheric nutritive dis- 
turbance of the nerve trigeminus can 
cause, besides the well-known neural- 
gia, paresis in connection with the ra- 
diating branches of the nerve facialis 
in the pesanserinus major and minor. 
I saw in this connection itching of the 
nose, or eruption on the diseased side of 
the tongue with vicariousness of taste, 
dryness in the mouth, but alwhys in 
connection with cold or change of the 
weather. That there is no central af- 
fection of the nerve facialis is clear by 
pressure upon the painful points, and 
the fact that cure is always effected by 
absorption occasioned by massage and 
electricity. In the cases where it is 
stated that the neuralgia ceases after 
stretching or resection of the nerve, 
we may suppose that by the interfer- 
ence of the operation the hyperplasia 
of the connective tissue has been ab- 
sorbed or has been removed. I be- 
lieve that the numerous catarrhal and 
other inflammations of the throat es- 
tablish engorgements of the lymph, 
and hyperplasias of the connective 
tissue about the neck and throat. 
Pressure upon the nerve cervicalis, 
especially along the muscle sterno- 
cleido-mastoideus, provokes shooting 
pains in the hand, sometimes ructus, 
singultus, sick stomach, and even an- 
gina pectoris. The upper border of 
the muscle cucullaris shows very often 
large, oblong swellings. Afflicted 
ligaments and muscles around the ver- 
tebrae may cause pseudo-ankylosis. 
On the upper arm the nerve brachialis 
to the condyle interims is often very 
sensitive. This is caused by lymph 
canals which are obliterated by lym- 
phangitis and which may be followed 
up the forearm and often have a nod- 
ulated indurated outline. The skin 
above the muscle deltoideus is con- 
nected with the latter, very painful, 
and underneath the ligaments of the 
shoulder are often attacked. The 
same remark may be made of the mus- 
cles of the forearm and the hand and 
finger-joints. The dorsal side of the 
intercarpal spaces is usually diseased, 
especially in writer’s cramp. The 
vola manus seldom takes part. The 
pseudo-ankylosis of the joints are usu- 
ally caused by affection of their nearest 18 
surroundings. Jurgenscnputs up the 
following painful points of the upper 
extremity: 
Axillary point, responding to the 
position of the plexus. 
Humeral point of the nerve axillaris 
back of humerus. 
Median point in the elbow. 
Ulnar point on cond. int. and again 
on the hand. 
On the thorax we meet with affection 
of the pectoralis major (mastodynia), 
giving an exceedingly coarse sensa- 
tion. 
Passing; to the fossa axillaris I saw 
especially among women, a pretty 
hard swelling connected with the skin, 
often of the size of a fist, which con- 
sists as elsewhere of a mass of thin 
round strings with evidently oblite- 
rated lymph collaterals. 
The twelve dorsal nerves are often 
the seat of rheumatic affection. With 
the intercostal nerves the vertebral 
points are less affected, corresponding 
to the exit from the foramen inter- 
vertebrale than the lateral points, 
which correspond about to the middle 
point between the vertebral column 
and sternum, where the ramus per- 
forans pierces the muscle. There are 
especially to the left of the mamma 
swellings larger than a dollar. They 
are easily found if you pass your 
linger with moderate pressure between 
the ribs above the intercostal spaces 
from the vertebral column to the 
sternum. These intercostal spaces 
feel slippery and ribbed and are very 
painful. This is the seat of the inter- 
costal neuralgia, which in its higher 
type—where it is not caused by vitium 
cordis—is called angina pectoris, and 
further down asthenic dyspepsia. 1 
have seen no patient who did not 
ascribe these pains to the heart or the 
lungs. The heart undoubtedly is 
sometimes a fleeted indirectly by irra- 
diation and causing palpitation, or 
directly with intermitting action on 
account of fatty degeneration. The 
symptoms from the heart disappear 
first under treatment. Pressure upon 
these places can cause ructus, singul- 
tus, yawning, inclination to vomit- 
ing, but only in protracted cases. 
The most diseased part is usually down 
from the first lumbar vertebra, on 
both sides of the proc. spinosi over 
the whole sacrum to the end of the 
os coccygis. The diameter of the 
hyperplasia may be several inches on 
the sacrum with single swellings of 
the size of a walnut. Pain is intense 
as if the back would break in two 
(lumbago). 
The nerve ileo-hypogastricus and 
ileo-inguinalis cause the visceral neu- 
ralgia which has its seat only in 
the abdominal walls, but is referred 
by the patient to the inside and is 
perhaps sometimes removed in the 
form of a thoroughly healthy ovary. 
I do not wish to say thereby that an 
inflammatory process of the sexual 
organs cannot produce engorgement 
of the lymph and hyperplasia with 
all its symptoms. From the crista 
ilei down to the sacrum there is again 
a favorite place of obliterated lymph 
collaterals. 
The os coccygis with the nervus 
coccygis is noted for eoccyalgia. The 
resection of the coccyx for neuralgia 
is just as necessary as the use of the 
gmillotine for headache. AVhether or 
not the enigmatical Luschka's gland 
be concerned in it sometimes I am not 
yet able to decide. This place is often 
very painful, but yields to treatment. 
I do not know whether or not the 
same disease occurs on the inner pelvic 
walls, but I doubt it, as the neighbor- 
hood Of the intestines does not favor 19 
stases of the lymph. Thure Brandt 
may give information about that. I 
have seen the parts innervated by the 
nerve genito-cruralis several times, 
exceedingly painful, but only among 
women, especially the mons veneris 
and the large labia pudenda. 
On the upper thigh an adhesion of 
all muscles mutually and with the 
skin is no rarity. Half and totally 
obliterated lymph canals in old cases 
are found with large swellings seem- 
ingly attached to the periosteum. The 
part underneath the nerve glutei di- 
rectly upon the pelvis is the seat of 
sciatica and not the nerve ischiaticus, 
though the latter is sometimes dis- 
eased. 
The mucous pockets of the knee are 
often afflicted and are conspicuous 
by their large swellings. They are 
often mistaken for gonitis, but care- 
ful investigation of the patella shows 
the knee-joint properly intact. They 
hardly ever suppurate. I have seen 
only one case where suppuration fol- 
lowed. Rheumatic swellings never 
suppurate, except after great injury. 
If the synovia is diseased there will 
be found fibrous and osseous precip- 
itations upon synovia and patella with 
floating bodies, which cause a loud 
rattling noise. 
The lower part of the thigh behaves 
like the other parts, particularly in 
the behavior of the tibia. The pass- 
ing finger feels, in fresh cases, uneven, 
small protuberances, in older cases, the 
hyperplasia of the periosteum is 
velvet-like; the massaging of it causes 
the unenviable feeling of rubbing the 
raw flesh with sand. 
The Achillodynia which Albert* 
described can often be seen, it is a 
hyperplasia of connective tissue of 
the vagina tendinis at its insertion, 
and results in adhesion with the under- 
lying tissues, which renders the whole 
muscle immobile and puts the foot by 
its contraction in pes equinus position. 
It has nothing to do with periostitis 
as Pitha thinks. Like Leo Rosenthal, 
1 was never able to find neuroma 
there, but I have found particles of 
fibrine of the size of a pea. The 
hyperplasia of the vagina tendinis is 
often so great that it projects beyond 
the tendon and the latter looks as if 
imbedded in it. Here belongs the 
case of Kussmaul’s clinic which has 
been described by Kreiss in No. 51 
Bed. Kl. Woch., 1886, as primary 
indurated myositis. It is a common 
case of chronic rheumatism, and I can 
at any time send a company of such 
cases to German clinics, if the ex- 
penses are paid. 
While the inside of the calcaneum 
is very seldom diseased there often is 
involvement of the periosteum of the 
outside which forms usually the ter- 
minal station of the sciatic telephone. 
The only participation of the 
foot joints are irreponible swellings 
which originally represented spon- 
taneous hernias of the synovial mem- 
brane caused by injury, but which 
were separated later. The dorsal 
skin of the foot rarely becomes ad- 
herent though these parts are some- 
times diseased, but more in the meta- 
tarsal spaces, which differ from the 
behavior of the metacarpal spaces in 
that they go down through this space 
to the ball of the foot, probably be- 
cause the metatarsal bones oppose 
expansion more than the metacarpal 
bones. There are cases where abso- 
lutely nothing more is affected than 
these interstices. One notices a 
slight swelling on the dorsal side, es- 
pecially of the first metatarsal space; 
there seems to be nothing strange on 
*\Vien. Med. Zts., No. 2, 1893. 20 
the ball of the foot. That this alone 
cannot be the cause of the exceedingly 
painful walk of the patients is evident; 
they walk with great effort, with two 
canes, as if they were on needles. But 
if you look at it more carefully 
you will notice that the ball of the 
foot is enlarged towards the toes, the 
line of demarcation which is normally 
between ball and toes, is often re- 
moved to the first toe joint and it 
looks as if there were webs between 
the toes. Simultaneously the capitula 
metatarsorum are exceedingly painful 
upon pressure. These afflictions are 
more frequent in men than in women. 
The ligaments and muscles of the 
planta show in general rheumatism, 
the same symptoms which we notice 
in inflammatory flat foot, or in torn 
ligaments from accidents, painfulness 
of the football and along the outside 
border of the foot with a culminating 
point on the prominence of the base 
of the fifth metatarsal bone. 
TREATMENT. 
Is it not peculiar that we have 
more specifics and other remedies 
for the diseases which we cannot 
help, than for others? There is a le- 
gion of anti-rheumatic medicines, and 
each has creditable bondsmen; how 
is that? Very simple. We know that 
these diseases appear in attacks with 
intervals of painfulness. Of course, 
the remedy which the patient took 
just when the remission came on was 
the principal agent which caused it, be 
it St. Jacob’s oil, colchicum, or guano. 
We often meet with the opinion 
that these diseases cannot be cured. I 
declare here, most emphatically by 
my experience, which includes the 
most desperate and most protracted 
cases in this line, that I never saw an 
incurable case, and that if once a cure 
has been established, no more symp- 
toms of neuralgias or neurasthenic 
sufferings will occur. The first grave 
cases of this kind left my treatment 
years ago. 
Of course 1 exclude from this prog- 
nosis cases with complications like 
chronic affections of our large glands. 
These cures are not accidental, but 
the result of long, assiduous work, and 
can be foretold and observed grada- 
tim in their different phases. It is 
certainly not the materia medica which 
celebrates triumphs in this connection. 
I believe the surgical treatment has 
prospect for enlarging here its do 
main. Too hard and voluminous swell- 
ings may be removed with the knife, 
it would be a gain of time, and in 
the same manner the accumulation of 
obsolete lymph canals, could be easily 
extirpated. Unfortunately I did not 
have experimental material on hand. 
It is certain that the knife would be 
the most rational method to remove 
synovial hernias. They require a very 
long time to be removed by other 
methods, and if not removed, they 
constitute a source of great feeble- 
ness and invalidity of the foot. 
Furthermore, there are the numer- 
ous contractions and pseudo-ankyloses 
which belong to the surgeon’s terri- 
tory. Ileal ankyloses occur and dis- 
tinguish themselves often by absorp- 
tion of the epiphyses, but they are 
rare. The pseudo - ankyloses are 
always secondary, caused by con- 
tractures of the muscles and retrac- 
tion of ligaments. I treat them with 
immersions of the limbs in hot water. 
As soon as the limbs are a little loose 
and softened up with immersion and 
following massage, I make tensions 
under chloroform, but am cautious 
and let myself be led entirely by my 
sensations in regard to the extent of 
them, and rather repeat them than 21 
force too much, because we some- 
times meet with infractions of spongy 
epiphyses, or with local paresis with 
circumscribed gangrene, which some- 
times hold on two or three months. 
I have never found it necessary 
to perform a tenotomy. I had, 
amongst others, a ease of pseudo- 
ankylosis of nearly all the joints 
of the body. They were from four 
to thirteen years old. A colleague 
who consulted with me seemed in- 
credulous, when I said all these con- 
tractures would be cured. I asked 
him on the spot, pointing towards 
a contracted knee-joint, if he did not 
think that might be stretched. He 
gave an affirmation to the question. 
The same when I asked this question 
in regard to a finger of a contracted 
hand. Well, I said, you concede the 
possibility of the cure of all these 
single contractures, why should they 
not all of them be cured? Never be 
bluffed by the appearance of seem- 
ingly incurable cases of multiple 
rheumatic pseudo-ankylosis. I per- 
formed on the above case, forced 
stretching and bending of thirty-five 
joints in two seances. Infraction of 
the epiphysis of the tibia, a paresis of 
the nerve radialis, lasting three 
months, two circumscribed gangrenes 
of the size of pennies was the con- 
sequence. This patient over fifty 
years old, after she had lost the use 
of her limbs for thirteen years, after 
five months’ treatment, was able to 
walk eighteen blocks every day. She 
learned to use her hands two years 
later, as she had forgotten the use of 
them, and only by little occupations in 
kitchen and home could be induced to 
use them again. During the four 
years which have supervened she has 
never had an attack of neuralgia or 
rheumatism and she is completely 
cured, but I had to fight a neuras- 
thenic melancholia which developed 
and lasted two years. 
Electricity is of great advantage, 
especially the constant current, to 
stop the beginning of degeneration of 
muscle and nerve elements. But that 
is all; without accompanying massage 
it is not of much use. 
INTERNAL, TREATMENT. 
The much lauded salicylic prepara- 
tions seem to be a kind of a “maid of 
all work,” if one believes its ador- 
ers. They are all right whenever 
cocci are present, for acute rheuma- 
tism, gonorrhoeic rheumatism, pre- 
served cherries or plums, but not in 
chronic rheumatism. 
Chronic rheumatism offers three 
indications: 
The first indication has the purpose 
of working against the changes of the 
blood, which are the result of the 
disease. A. G. Garrod* examined the 
blood of eighty rheumatics during 
their disease and arrived at the fol- 
lowing conclusions: 
‘ ‘An attack of rheumatism is always 
accompanied by a considerable loss 
of red blood corpuscles, which appears 
in the beginning of the attack. In 
prolonged attacks there is no pro- 
gressive decrease to be noticed, still 
their number remains on the same 
low average, whether there be any 
fever or not, The leucocytes are at 
the same time immensely increased. 
As soon as the attack is over the red 
corpuscles augment astonishingly fast 
and these changes give us a much 
better picture of the states of the dis- 
ease than the temperature curve. The 
anaemia of rheumatism is either an 
acute oligocythaemia, from which 
rapid recovery results, or a more 
* Lancet, Royal Med. Surg. Soc., Feb. 13* 
1892. 22 
chronic pseudo-chlorosis, the latter in 
few cases. The higher the fever the 
more leucocytes, but in sub-acute cases 
also there takes place an increase of 
them, likewise of the number of the 
blood platelets. ‘We see by that that 
iron is properly indicated.’ ” 
The second indication for treatment 
of chronic rheumatism consists in ex- 
ploring the causes of the engorgement 
of the lymph and to remove them, if 
found. In regard to its origin we 
must consider the fact that far more 
women are victims. The cause of this 
may be in the want of exercise in the 
female sex. 
The lower extremities must be well 
exercised in all their motions, if the 
lymph is to be forwarded from the 
legs to the abdomen and from there 
further up. Instead of this, the first 
rule of conduct which a suffering 
woman receives from her gynaecolo- 
gist is not to mount stairways; “ this 
does harm to the much abused uterus. ’ ’ 
This extremely quiet mode of life 
thus regulated has, of course, its in- 
fluence upon the peristaltic motion of 
the lymph of the intestinal cavities 
does not give place to that of the 
limbs. Stagnation in the trunk and 
extremities follows and plethora 
hyper-albuminosa in the glands and 
organs of the cavities results. The 
plethora of the uterus causes the for- 
mation of numerous leucocytes and 
leucorrhoea with all its peri and para- 
metritic processes. The naturally 
more developed lymphatic system of 
the female sex certainly is a predis- 
ponent. With men it is more the 
overcharge of the lymph and blood 
with food which, of itself, or com- 
bined with want of exercise and oc- 
casional cold, offers the basis of dis- 
ease. Physically it is right that the 
stagnation first originates where the 
lymph remains longest, which is in 
the remotest periphery of the body, 
the feet and hands. We see how im- 
portant a factor is the peristaltic mo- 
tion, for as soon as the bowels are 
opened we have a relief of the symp- 
toms. Constipation accentuates them. 
Therefore, keep the bowels open. 
Arsenic can be administered alter- 
nately with iron, even to well nour- 
ished persons. The treatment is very 
severe and improvement of the fluids 
of the body is imperative. 
Regarding the influence of iodide 
of potassium upon the indurated 
swellings, I can say little. My advice 
is to do without it; its effect upon the 
rheumatic swellings is more than 
doubtful, anyway; it does not encour- 
age the action of the stomach and 
compromises the kidneys when given 
in the customary absurdly high doses. 
Still we have a remedy to satisfy 
the third indication and to wash away 
thefibrine formation, that is the meth- 
odical use of much hot water con 
nected with diuresis. Here is the way 
to the often surprising successes of 
the thermes, and it is surely not alone 
the hot water which is responsible for 
the beneficial effect, but their slight 
content of alkalies too, as I had op- 
portunity to notice at the Hot Springs, 
Ark. A weak solution of alkalies, 
especially sodium sulphate, is known 
to dissolve fibrine. I will have occa- 
sion to publish my unfinished experi- 
ments which are in the line of intro- 
ducing a solution of sodium sulphate 
in hot water into the swellings. This 
treatment, with quantities of hot water 
is also necessary, because the princi- 
pally mechanical treatment physio- 
logically thickens the blood and in- 
creases the lymph, so much so, that 23 
continued passive motions kill an ani- 
mal on the spot by thickening of the 
blood. (Landois.) 
The above quoted treatments may 
produce a passing improvement, but 
have little permanent success if not 
connected with thoronghmassage,pas- 
sive motions and Swedish exercises. I 
do not mean the daily massage of the 
massage professors, which is good 
enough to keep the circulation of a 
healthy person going; I mean the 
weighed massage from the hand of a 
physician who is experienced in it, 
who first hunts up the swellings and 
knows where to find them and then 
tears off the adhesions and removes 
the swellings by pressure. It takes 
strength. I do not hesitate to state 
that sometimes in completely atonic 
cases of fibrous degenerated muscular 
tissue of desperate old cases, I even 
produce contusions, to revive the cir- 
culation. That is, however, excep- 
tional. It is evident that the tearing 
off of adhesions causes severe pains 
which, however, give way very soon 
after a few weeks. The treatment is 
of long duration, but always satisfac- 
tory, because always improving the 
patient and, if continued long enough, 
curing him. 
I wish to cite here an instructive 
experiment by Zabludowsky* which 
shows how the elements of our tissues 
saturate the surrounding nutritive 
fluids with effete matter and get 
fatigued, and how they regain their 
functions by removal of the lymph by 
massage and so making place for new 
fluid. 
‘‘A person raised a weight of one 
kilo. 840 times in intervals of one 
second by maximally bending the 
elbow joint from the table to the 
shoulder upon which his forearm 
rested. Later he was not able even 
after hard effort to do anything. After 
I had massaged the young man’s arm 
for live minutes he was able to raise 
without effort in the same rhythm as 
before, the same weight 1100 times.” 
This treatment has to be changed in 
some way in cases of neurasthenic 
rheumatism where there are decided 
signs of parenchymatous disturbance 
of the nutrition of parts of the brain. 
We must then also remove the ac- 
cumulated effete matter by massage 
of the neck with passive motions 
of the latter. If we add general deep 
massage of the whole body we im- 
prove the composition of blood and 
lymph better than with anything 
else, though it is usually simultaneously 
necessary for the removal of the com- 
plicating rheumatic swellings in other 
parts of the body which almost always 
accompany cerebral neurasthenia. 
The methodical use of fruits as they 
are prescribing grapes in Switzerland, 
is the best to keep up peristaltic mo- 
tion. Stimulants are splendid, if 
used by the physician himself, to 
rally his sinking strength for the ben- 
efit of his patient, but otherwise no, 
most emphatically, no. Mental and 
other kind of work must be mild and 
not too uniform. If the cares and 
worries of business exhaust the cells of 
the brain, let the man rest by indulg- 
ing in a little game of poker, with the 
ante just high enough to make it in- 
teresting ; that rests him more than 
hours of neurasthenic sleep. Such, 
who make poker playing their busi- 
ness and get neurasthenia (I never 
saw that, though), I would advise to go 
and listen to a good sermon, but I be- 
lieve that I would have better luck 
with my advice, with the clergy and 
business men, than with gamblers. 
*Die Bedeutung der Massage, I)r. Zablu- 
dowskv. Berlin, 1S8B. 24 
Plain food, and not too much, for too 
much seasoning acts like too much 
uniform work and thinking, or alco- 
hol. It exhausts the parenchymatous 
vitality. 
I cannot close without mentioning 
neurasthenic melancholia. It often 
accompanies severe cases of rheuma- 
tism and is evidently based upon the 
sa me disturbances of parenchymatous 
nutrition of the responding parts of the 
brain. Its treatment is always suc- 
cessful, not by psychical treatment but 
by general massage, especially of the 
lymph canals of the neck in connection 
with the use of drastics. We may also 
expect to give an impulse for judging 
differently and treating more success- 
fully those mental diseases, which are 
based upon neurasthenic disturbances. 
Lastly, I wish to draw attention 
to a neurosis, which can present itself 
in severe cases during long treatment 
and may prove serious, both for patient 
and physician, it is—the asthenia of 
the nervus reruin.  
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